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Based on document review, observation, and interview, it was determined that the Hospital failed to provide care in a safe setting and promote each patient's rights. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to provide care in a safe setting by failing to ensure that the patient rooms on the adult behavioral health unit (ABHU) were free from ligature risks. (A-144)


The immediate jeopardy was identified on 03/29/2023, due to the Hospital's failure to ensure that care was provided in a safe setting by failing to ensure the patient rooms on the adult behavioral health unit (ABHU) were free from ligature risks. The IJ was cited at 42 CFR 482.13, Patient Rights, and was announced on 03/29/2023 at 9:30 AM, during a meeting with the Vice-President of Quality and Patient Safety, Vice-President of Patient Care Services/Chief Nurse Officer, General Counsel, VP of Operations, Corporate Chief Medical Officer, Chief Operations Officer, Business Development Manager, Quality Manager, and Chief Medical Officer. The IJ was not removed by the survey exit date of 03/30/2023.

Based on document review, observation, and interview, it was determined that for 1 of 1 Behavioral Health Units/BHU (Adult), the Hospital failed to provide care in a safe setting by failing to ensure that the patient rooms on the adult behavioral health unit (ABHU) were free from ligature risks and patient safety interventions were in place to mitigate the presence of ligature risks. This has the potential to affect the safety of the current psychiatric patients (12 patients were on suicide precautions between 3/27/2023-3/28/2023) and any future psychiatric patients who become suicidal.

Findings include:

1. The Hospital's policy titled, "Environmental Risk Assessment for Ligature Risk Safety" (dated 1/2022), was reviewed and required, "Staff members will continuously maintain awareness and observe for safety issues, including potential ligature safety risks. If any potential ligature risks are identified the patients' safety will be prioritized, risk will be immediately resolved or continuously monitored until able to be fixed by engineering..."

2. The Hospital's most recent environmental assessment of the ABHU, dated 2/15/2023, did not identify any ligature risks within the patient rooms.

3. On 3/27/2023, from approximately 10:54 AM to 12:59 PM, an observational tour of the ABHU was conducted. There were 20 patients on census, of which 1 patient (Pt. #11) had orders for Line of Sight/LOS (constant visual observation) monitoring (due to the need for a medical bed for sleep apnea), and 11 patients (Pts. #12-#22) on the unit were on suicide precautions.
- At approximately 11:03 AM, Pt. #11 was noted to be in his assigned room alone with no staff visual monitoring Pt. #11. There was a movable, electric (medical) bed with wheels present. The bed had a headboard, 4 side rails, and a footboard, with openings that could be used as anchor points for ligatures. The bed also had 2 cords (approximately 4 feet in length) hanging on the headboard which could be used for strangulation/ligature.
- At approximately 11:13 AM, Pt. #11 exited his room and was walking along the hallway. The room door was left open and the medical bed was accessible to all other patients on the unit. It was noted that the hallway was not monitored at all times by a staff member to prevent patients from entering Pt #11's room.

4. A second tour of the ABHU was conducted on 3/28/2023, from approximately 10:59 AM to 11:30 AM. There were 18 patients on census, including Pt. #11 and 8 patients (Pts. #12, #13, #15, #17, #18-#21, and #24) that were on suicide precautions. The unit consisted of 14 rooms, and the following ligature risks were observed:
- Each room had a free-standing porcelain toilet hanging approximately 2-feet off the ground. The toilets had no base that connected to the floor, creating an empty space below the toilet to allow the toilet bowl to be used as an anchore point for hanging. The toilets also had a movable U-shaped toilet seat which could be used as a ligature point. There was also a small gap (approximately 1-centimeter) between the toilet seat and the back of the toilet that could be used as an anchor point.
- Rooms #401, #402, #403, #416, #417 & #418: approximately 2-inch thick door alarms shaped like a stop sign were observed protruding on the outside of the door (the alarm would be inside the room and not visible from the hallway when the door is open).
- Rooms #402, 404, #405, #406 & #407: metal protruding 1-inch soap holders were in showers.
- Rooms #418 was noted to be unoccupied and the door was closed. The door was unable to be locked and the door alarm present was not activated.
- At approximately 11:00 AM, Pt. #11 was lying in the medical bed in his room, and there was no staff member with direct visual observation of Pt. #11.

5. On 3/27/2023, at approximately 11:15 AM, an interview was conducted with the BHU Operations Manager (E#7). E#7 stated that Pt. #11 should be on LOS monitoring when he is in the room due to the medical bed being present and posing a risk for ligature. E#7 stated that there isn't someone assigned to monitor/follow Pt. #11 when he is outside of his room. E#7 stated that staff do not monitor the medical bed and the rooms doors are unable to be locked. E#7 stated that staff perform environmental rounds each shift (2 shifts per day) and stated that staff are monitoring the rooms for any safety or maintenance issues (such as contraband and/or ligature risks).

Based on observation, document review, and interview, it was determined that for 1 of 4 anesthesia carts in the main operating room (OR #7), the Hospital failed to ensure that the anesthesia cart containing drugs/medications was kept secured, as required.

Findings include:

1. On 3/28/2023 at approximately 9:30 AM, an observational tour of the Hospital's main operating room was conducted. In OR #7, an anesthesia cart containing medications such as, but not limited to: lidocaine/numbing medication, epinephrine/emergency medication to treat severe allergic reaction, labetalol/blood pressure medication, and heparin/anticoagulant was not locked.

2. On 3/28/2023, the Hospital's policy titled, "Pharmacy Department Security" (dated 2/2023) was reviewed and indicated, "... II. The Pharmacy Department shall implement and maintain procedures to ensure security of pharmaceuticals and medications... V. Procedure... H. Restriction and lock/key controls are exercised for the security of drugs outside the confines of the Pharmacy Department including operating rooms... 1. Medication carts are secured..."

3. On 3/28/2023, findings were discussed with MD #5 (Chief Medical Officer). MD #5 stated that the anesthesia cart should have been locked to ensure that the medications were kept secured.

A. Based on document review, observation, and interview, it was determined that the Hospital failed to manage daily dietary services by not ensuring that foods were labeled with an opened or use-by date. This had the potential to affect the 41 patients receiving oral diets on 3/27/2023.

Findings included:

1. The Hospital's policy titled, "Precautions in Handling, Preparing and Storing of Food" (dated 2/2023) was reviewed and indicated, "...All prepared and proportioned foods or those stored in pans...are labeled with the name of the food and discard date of the item...:items will be dated with date opened..."

2. A tour of Dietary Services was conducted on 3/27/2023 at 11:15 AM. The following was observed:

- The walk-in refrigerator #1 contained an open bag of chicken breasts (undated and no use-by date).
- The walk-in refrigerator #2 contained an open bag of open shredded cheese (undated and no use-by date).
- The freezer contained an open bag of frozen broccoli (undated and no use-by date) and an open bag of mixed vegetables (undated and no use-by date).
- The food storage room contained an open bag of stuffing (undated and no use-by date).

3. During the tour, the Director of Dietary (E#1) stated that all items that have been opened, must be labeled with an opened date and use-by date.


B. Based on document review, observation, and interview, it was determined for 1 of 1 prep cook (E #2), the Hospital failed to ensure a hairnet was worn, as required.

Findings included:

1. The Hospital's policy titled, "Traffic Control" (dated 2/2023) was reviewed and indicated, "...Use of hairnets/bonnets and other protective clothing are to be worn by all personnel..."

2. A tour of Dietary Services was conducted on 3/27/2023 at 11:15 AM. The following was observed:
- E #2 was observed preparing hot food for lunch wearing a bonnet that did not cover her ponytail.

3. On 3/27/2023 at 11:30 AM, an interview was conducted with the Director of Dietary (E #1). E #1 stated that it is alright if E #2 wears a bonnet even though the bonnet did not cover her ponytail.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted March 27 & 28, 2023, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted March 27 & 28, 2023, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review, observation and interview, it was determined that for 1 of 1 pediatric crash cart in the Emergency Department, the Hospital failed to ensure that the crash cart was checked daily, as required.

Findings include:

1. On 3/27/2023, the Hospital's policy titled, "Crash Cart Maintenance" (dated 2/2023) was reviewed and indicated, "...Crash carts are checked daily..."

2. On 3/27/2023 at approximately 10:00 AM, an observational tour was conducted in the Emergency Department. The pediatric crash cart log (dated March 2023) was reviewed. The pediatric crash cart had not been checked since 3/22/2023.

3. On 3/27/2023 at 10:10 AM, an interview was conducted with the Manager of the Emergency Department (E #3). E #3 stated that the pediatric crash cart should be checked daily.

Based on observation, document review and interview, it was determined that the Hospital failed to ensure an effective Infection Control Program, with adherence to infection control practices and sanitary conditions maintained to prevent cross contamination. This has the potential to affect all staff and patients, who receive care by the Hospital. As a result, it was determined the Condition of Participation, 42 CFR 482.42, Infection Prevention Control Antibiotic Stewardship was not met.

Findings include:

1. The Hospital failed to ensure that the disinfection solution for dishwashing was checked with current test strips as required to ensure a clean and sanitary environment to avoid sources and transmission of infection. See deficiency A-750.

Based on observation, document review and interview, it was determined that for 1 of 2 staff (MD #6/Infectious Disease Physician) observed providing care to a patient on contact precautions, the Hospital failed to ensure that the staff followed the method for preventing and controlling transmission of infections within the Hospital.

1. On 3/27/2023 at approximately 11:00 AM, an observational tour of the Hospital's intensive care unit (ICU) was conducted. In ICU Room 7, signage was posted indicating that a patient (Pt. #30) was on contact isolation. While inside the room, MD #6 was touching and examining Pt. #30 without wearing a gown.

2. On 3/27/2023, the clinical record for Pt. #30 was reviewed. On 3/18/2023, Pt. #30 was admitted to the ICU due to hypertensive crisis. On 3/26/2023, a stool sample was collected and a physician's order was obtained to examine Pt. #30's stool for Clostridium Difficile/C-diff (bacteria that causes inflammation of the colon). As of 3/27/2023, results of the test has not come back to rule out suspicion for C-diff.

3. On 3/27/2023, the Hospital's policy titled, "Standard and Transmission Based Precautions: Isolation" (dated 2021) was reviewed and included, "... V. Procedure... 1. Standard Precautions... e. Gowns are worn to protect skin and prevent soiling of clothing during procedures and patient-care activities... 2. Transmission-Based Precautions. Transmission-based precautions are designed for patients known or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens... There are three types of transmission-based precautions... 3. Contact Precautions... c.. In addition to wearing a gown as outlined under Standard Precautions, wear a gown when entering the room..."

4. On 3/27/2023, findings were discussed with E #20 (Vice President of Quality and Patient Safety) and E #32 (ICU Charge Nurse). E #32 stated that Pt. #30 has not been ruled out for C-diff because the results of the test has not come back. E #20 and E #32 stated that MD #6 should have worn a gown while examining Pt. #30.

Based on document review, observation, and interview, it was determined that for 1 of 1 dishwasher technician (E #10) observed, the Hospital failed to ensure the proper disinfection process for manually cleaning/disinfection of cookware and pots/pans, was completed to ensure a clean and sanitary environment to avoid sources and transmission of infection. This potentially affects 42 patients on census receiving meals service as of 03/27/2023.

Findings include:

1. On 3/27/2023, the Hospital's procedure titled, "Procedure - Pots & Pans, Cookware - Cleaning & Sanitizing" (undated) was reviewed and indicated "Manual Method - cleaning equipment - pots & pans, cookware:
-Ensure the 3 compartment sink is clean and ready for use. Sink #1 is for wash, sink #2 is for rinse and sink #3 is for sanitizing.
-Fill sink 1 with water that a minimum of 110 degrees. Add pots/pans and soak for at least 5-10 minutes depending on soil level.
-While pots and pans are soaking in sink 1, fill Sink #2 (rinse sink) with hot water. Next fill sink #3 (sanitizer sink) with a water and sanitizer solution. Verify temperature is above 75 degrees.
-Use test strips to ensure concentration of sanitizer in sink #3 is within proper efficacy range (dip test paper in container solution for 10 seconds, remove and compare test paper to the color chart on the test strip package)
-After pots and pans have soaked for at least 5-10 minutes, scrub all surfaces with nylon brush or scrub pad and allow excess water to run back into wash sink.
-Next submerge pan in hot water rinse (sink 2) and allow excess water to run back into rinse sink.
-Then submerge in sanitizer sink (sink 3) for one minute
-Turn upside down on a drain board. Do not wipe dry."

3. On 3/27/2023 at approximately 1:30 PM, E #10 was observed cleaning and disinfecting dirty metal food containers using a manual method. The following was observed:
-E #10 checked the temperature in sink #1, and it was 109 degrees.
-E #10 dipped the dirty metal food containers in sink #1 for 5 seconds; then placed the metal food containers in sink #2 for 1 second; and then sink #3 for approximately 5 seconds.
- Upon surveyor request, E #10 checked sink #3 with sanitizer test strips that had an expiration date of 7/2022. The strip noted that sink #3 was within normal range. E #10 dipped the sanitizer test strip in sink #3 for 1 second instead of 10 seconds.
-E #10 continued to clean/disinfect the metal food containers in sink #3 after using expired sanitizer test strips to test sink #3.
-E #10 then placed the wet metal food containers on a shelf ready for use. The food metal containers were not placed upside down on a drain board to dry.

4. On 3/27/2023 at 1:45 PM, an interview was conducted with the Director of Food Services ( E#1). E #1 stated that current test strips should be used for sink #3 for cleaning and disinfecting the food metal pans and pots. E #1 stated that she was going to contact the company for test strips that had a current date.

Based on document review, observation, and interview, it was determined that for 1 of 1 physician (MD #3/anesthesiologist), 1 of 1 operating room/OR Manager (E# 9), and 2 of 2 Surgical Technicians (E#12, E#13) observed in OR #5, the Hospital failed to ensure that the policy regarding surgical attire was followed.

Findings include:

1. On 03/28/2023, the Hospital's policy titled, "Surgical/Procedural Areas Attire" (dated 06/2021) was reviewed and indicated, "...Outside shoes are required to be covered... Head and facial hair including sideburns, beards, and neckline is covered when entering the semi restricted and restricted area of the surgical suite ...Jewelry is not to be worn in the operating rooms ...."

2. On 03/28/2023 between 8:40 am and 9:30 am, an observational tour of OR #5 was conducted. OR #5 was a restricted area and sterile field was present At approximately 8:40am, E#12 was observed inside of OR #5 without shoe covers and also wearing earrings and a necklace. At approximately 8:44am, E#9 entered OR #5 without wearing any shoe covers and also wearing earrings. At approximately 8:55am, (MD #3/anesthesiologist) entered OR #5 without wearing any shoes covers and without beard fully covered. MD #3 was wearing shoes from the outside. At approximately 9:04 am, E#13 (Surgical Technician) entered the OR without wearing any shoes covers and also wearing earrings. E #13 was wearing shoes from the outside.

3. On 03/28/2023, at approximately 9:30 am, an interview was conducted with (E#8/Clinical Nurse Manager). E#8 stated that E#8 is not sure if shoe covers, jewelry, and beard covers are included in the policy and required to be worn in the operating room.